Login
Create Account
Application Deadline! Medical Student and International Applications Close July 31.

AAOS Now / Issue: June 2025 / clinical02

AAOS Now

Published 6/26/2025
|
Michael DeRogatis, MD, MS; Paul S. Issack, MD, PhD, FAAOS, FACS
Clinical Practice Management Total Joint

Climbing Revision Arthroplasty Rates Pose Financial Threat to Healthcare System

The aging of the baby-boomer population and advances in implant fixation, which have permitted total hip arthroplasty (THA) and total knee arthroplasty (TKA) to be performed in younger patients, have resulted in a dramatic increase in the number of these procedures. Epidemiological studies have projected that by 2030, demand for primary THA and TKA will increase by 174 percent and 673 percent. As a result, there is expected to be a major increase in the number of revision THA (rTHA) and revision TKA (rTKA) procedures, estimated at 137 percent and 601 percent, respectively. These complex procedures pose a significant financial burden for patients, orthopaedic surgeons, and the healthcare system.

Increased complexity means increased costs
rTHA and rTKA, either exchange of one or more components or placement of antibiotic spacers, are technically difficult surgeries fraught with complications. Compared with primary joint replacement, revision procedures are substantially longer, and they have greater potential for blood loss, greater need for transfusion, and higher rates of infection. They also have higher risk of instability, aseptic loosening, and periprosthetic fracture. As a result, survivorship of rTHA and rTKA is significantly lower than their respective primary counterparts.

In addition to being technically challenging and time-consuming operations, revision surgeries are associated with greater cost, greater liability, and lower reimbursement per minute for the hospital and surgeon compared to primary THA and TKA. This creates a situation where patients needing revision arthroplasty may have limited access to care, as it can be difficult to find trained surgeons willing to do these operations.

Revision arthroplasty procedures have created a major financial burden on the healthcare system. Longer OR times, longer hospital stays, more expensive revision arthroplasty implants, the need for inpatient rehabilitation, and additional consultations (such as infectious diseases specialists and long-term IV antibiotics) contribute to the increased cost of these surgeries. Infected primary arthroplasty alone is expected create a combined annual hospital cost of $1.85 billion by 2030.

The liability associated with performing rTHA and rTKA exceeds that of performing primary arthroplasty. In a study of malpractice claims, the average indemnity payment for primary THA was $170,552, whereas the average indemnity payment for rTHA was $601,914—3.5 times higher. For primary TKA, the average indemnity payment was $118,740, compared with $204,249 for rTKA. The greater liability associated with these cases can discourage many community hospitals from performing them, as the risk to the hospital may not be worth the reimbursement per time invested.

Unequal reimbursement
Revision total joint arthroplasty (TJA) is a complex surgery that requires substantial technical expertise, and it is associated with longer OR time, greater risk of complications, greater liability, and significant physical effort. It should, therefore, be surprising that the reimbursement is disproportionately low compared to that of primary THA and TKA. Over the past two decades, Medicare physician fee reimbursements have not kept up with inflation. In their 2018 article in the Journal of Arthroplasty, Sodhi and colleagues noted that although revision arthroplasties are longer and more complex than primary procedures, the relative value unit (RVU) per minute is significantly higher in primary cases. They reported an annual reimbursement difference of $113,052 for an individual surgeon performing primary versus revision hip replacement.

In 2022, Patel and colleagues authored two studies published in the Journal of Arthroplasty comparing RVU compensation between primary and revision indications for THA and TKA, respectively. They reported that the average operative time was 146 minutes to perform all-component THA revision and 184 minutes for spacer placement, compared with 86 minutes to complete a primary THA. They noted that primary THAs generated a reimbursement of $27 per minute and $102 per RVU, whereas both component hip revisions and spacer placements generated reimbursement rates of $21 and $14 per minute and $80 and $76 per RVU. Primary TKA generated a reimbursement of $25 per minute and $94 per RVU, whereas both component knee revisions and spacer placements generated reimbursement rates of $16 and $91 per minute and $11 and $84 per RVU, respectively.

The disparate reimbursement for primary and revision arthroplasty can compromise the delivery of high-quality patient care. Patel and colleagues noted that because of poor reimbursement for rTHA and rTKA, many surgeons choose to perform limited revision surgeries. This includes procedures such as acetabular liner and femoral head exchange, as well as knee polyethylene liner exchange, where the reimbursement per minute more closely approximates that of primary arthroplasty. This may create a situation where surgeons inappropriately perform a simpler procedure when a patient requires explantation and antibiotic spacer placement, a more laborious and technically difficult operation with lower reimbursement. Many surgeons may choose to avoid longer, higher-risk operations because they are simply not worth doing due to risks, liability, and poor reimbursement. Furthermore, not performing the appropriate procedure (explantation and spacer placement) in a timely manner may make eradication of infection more difficult.

Impact on access to care
Because increases in hospital reimbursements for revision joint arthroplasty have lagged behind increasing labor and implant costs, hospitals are facing the challenge of being able to provide high-quality care and maintain financial solvency.

The cuts for THA and TKA made by the Centers for Medicare & Medicaid Services affect patients with Medicare, who make up the majority of patients requiring revisions. Many surgeons may choose to drop Medicare because of these cuts. Access to high-quality care for this patient population may become limited.

Improving reimbursement for these challenging surgeries is necessary to incentivize surgeons to continue performing these needed operations. In an editorial published in Arthroplasty Today, Levine and colleagues proposed the creation of arthroplasty centers of excellence that would be equipped with the resources to tackle complex revision surgeries in a more efficient manner. Such centers would perform a high volume of these cases with dedicated teams, which would be expected to result in better outcomes and reduced operating costs.

Michael DeRogatis, MD, MS, is an orthopaedic surgery resident at St. Luke’s University Health Network in Bethlehem, Pennsylvania.

Paul S. Issack, MD, PhD, FAAOS, FACS, is a clinical associate professor in the Department of Orthopaedic Surgery, Weill Cornell Medical College, and a trauma and adult reconstruction orthopaedic surgeon at New York–Presbyterian/Lower Manhattan Hospital. He is also a member of the AAOS Now Editorial Board.

References

  1. Kurtz S, Ong K, Lau E, et al: Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89(4):780-5.
  2. Schwartz AM, Farley KX, Guild GN, et al: Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2030. J Arthroplasty 2020;35(6S):S79-85.
  3. Acuna AJ, Jella TK, Samuel LT, et al: Inflation-adjusted Medicare reimbursement for revision hip arthroplasty: study showing significant decrease from 2002 to 2019. J Bone Joint Surg Am 2021;103(13):1212-9.
  4. Ashkenazi I, Christensen T, Oakley C, et al: Trends in revision total hip arthroplasty cost, revenue, and contribution margin 2011 to 2021. J Arthroplasty 2023;38(7S):S34-8.
  5. Ashkenazi I, Christensen T, Ward SA, et al: Trends in revenue and cost for revision total knee arthroplasty. J Arthroplasty 2023;38(7 Suppl 2):S97-102.
  6. Fang CJ, Shaker JM, Drew JM, et al: The cost of hip and knee revision arthroplasty by diagnosis-related groups: comparing time-driven activity-based costing and traditional accounting. J Arthroplasty 2021;36(8):2674-9 e3.
  7. Fang CJ, Shaker JM, Ward DM, et al: Financial burden of revision hip and knee arthroplasty at an orthopedic specialty hospital: higher costs and unequal reimbursements. J Arthroplasty 2021;36(8):2680-4.
  8. Jella TK, Acuna AJ, Samuel LT, et al: Medicare physician fee reimbursement for revision total knee arthroplasty has not kept up with inflation from 2002 to 2019. J Bone Joint Surg Am 2021;103(9):778-85.
  9. Patel A, Oladipo V, Kerzner B, et al: A retrospective review of reimbursement in revision total hip arthroplasty: a disparity between case complexity and RVU compensation. J Arthroplasty 2022;37(8S):S807-13.
  10. Patel A, Oladipo VA, Kerzner B, et al: A retrospective review of relative value units in revision total knee arthroplasty: a dichotomy between surgical complexity and reimbursement. J Arthroplasty 2022;37(6S):S44-9.
  11. Premkumar A, Kolin DA, Farley KX, et al: Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. J Arthroplasty 2021;36(5):1484-9 e3.
  12. Rizk AA, Jella TK, Cwalina TB, et al: Are trends in revision total joint arthroplasty sustainable? Declining inflation-adjusted Medicare reimbursement for hospitalizations. J Arthroplasty 2023;38(7 Suppl 2):S91-6.
  13. Sodhi N, Piuzzi NS, Khlopas A, et al: Are we appropriately compensated by relative value units for primary vs revision total hip arthroplasty? J Arthroplasty 2018;33(2):340-4.
  14. Roof MA, Levine BR, Schwarzkopf R: The hidden cost of revision hip and knee arthroplasty. Arthroplast Today 2022;16:167-8.
  15. Bohl DD, Samuel AM, Basques BA, et al.: How much do adverse event rates differ between primary and revision total joint arthroplasty? J Arthroplasty 2016;31(3):596-602.
  16. Patterson DC, Grelsamer RP, Bronson MJ, et al.: Lawsuits after primary and revision total hip arthroplasties: a malpractice claims analysis. J Arthroplasty 2017;32(10):2958-62.
  17. Patterson DC, Grelsamer R, Bronson MJ, et al.: Lawsuits after primary and revision total knee arthroplasty: a malpractice claims analysis. J Am Acad Orthop Surg 2017;25(10):e235-42.